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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700284
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:19:14 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2020 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20200921134841
FACILITY NAME:MINNESOTA HOME CAREFACILITY NUMBER:
342700284
ADMINISTRATOR:OKYERE, VERAFACILITY TYPE:
740
ADDRESS:7448 MINNESOTA DRIVETELEPHONE:
(916) 842-9025
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:0CENSUS: 4DATE:
07/07/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Vera Okyere, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Medications not given as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegation listed above. LPA met with Administrator Vera Okyere during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: masks.
LPA investigated the allegation "medications not given as prescribed". LPA interviewed residents in care, conducted file reviews, and reviewed residents medications. Relevant party reported facility did not give medications as prescribed. LPA reviewed facility documentation in which it documents R1 refused medications often. LPA interviewed 3 residents in which they stated they are given their medications on a timely basis daily.
Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2020 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20200921134841

FACILITY NAME:MINNESOTA HOME CAREFACILITY NUMBER:
342700284
ADMINISTRATOR:OKYERE, VERAFACILITY TYPE:
740
ADDRESS:7448 MINNESOTA DRIVETELEPHONE:
(916) 842-9025
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:0CENSUS: 4DATE:
07/07/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Vera Okyere, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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9
Facility is unkempt
Food being served is rotten
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegation listed above. LPA met with Administrator Vera Okyere during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: masks.
LPA investigated allegation, "Facility is unkempt". LPA conducted a facility tour and interviewed residents and administrator. LPA toured the facility on 9/24/20, 4/7/2021, and 7/7/2021 and observed the facility had clean floors and bathrooms, and resident rooms were organized and appeared cleaned. LPA did not observe an unpleasant odor, and residents appeared to be clean and comfortable. LPA interviewed 3 residents in which they stated that the facility staff cleans their room and facility often.
Continuation on 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20200921134841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MINNESOTA HOME CARE
FACILITY NUMBER: 342700284
VISIT DATE: 07/07/2021
NARRATIVE
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LPA interviewed administrator/licensee in which they stated staff clean the facility daily and as needed. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

LPA investigated the allegation, "Food being served is rotten". LPA conducted a facility tour, interviewed residents, and staff. LPA toured the facility on 9/24/20, 4/7/2021, and 7/7/2021 and observed 2-day perishable and 7-day non-perishable amount of food. LPA did not observe any rotting food or expired food in the facility. LPA conducted interviews with 3 residents in which they stated they have never been served rotting or expired foods. LPA interviewed administrator in which they stated they do not serve rotting foods and go grocery shopping weekly for the residents. Administrator stated R1 was particular in their food choices and would specifically go grocery shopping for the food they requested. Due to the information gathered, LPA finds allegation to be UNFOUNDED.


The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2020 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20200921134841

FACILITY NAME:MINNESOTA HOME CAREFACILITY NUMBER:
342700284
ADMINISTRATOR:OKYERE, VERAFACILITY TYPE:
740
ADDRESS:7448 MINNESOTA DRIVETELEPHONE:
(916) 842-9025
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:0CENSUS: 4DATE:
07/07/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Vera Okyere, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Facility staff not meeting resident needs
Staff verbally abusing residents
Staff not seeking medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegation listed above. LPA met with Administrator Vera Okyere during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: masks.
LPA investigated the allegation "Facility staff not meeting resident needs". LPA conducted interviews with resident and staff and reviewed facility documentation. Administrator stated R1 would refuse continence care, bathing, and medications frequently. LPA reviewed facility documentation in which it states resident refused care or medications 40 times from time of admission on 7/30/20 to 9/18/20. R1 reported to relevant party that facility staff were neglecting them.
Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20200921134841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MINNESOTA HOME CARE
FACILITY NUMBER: 342700284
VISIT DATE: 07/07/2021
NARRATIVE
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LPA interviewed 3 residents at the facility in which they stated their care needs are being met by facility staff. Due to the information gathered, LPA finds allegations to be UNSUBSTANTIATED.

LPA investigated allegation, "Staff verbally abusing residents". R1 reported to relevant party that staff yelled at them on a daily basis. LPA interviewed 3 residents at the facility in which they stated staff do not yell at the residents. 1 resident stated they have heard staff get upset with each other but not with other residents. 1 resident stated they had heard staff talk firmly to other residents but not yell at them. LPA interviewed administrator in which they stated resident would yell and hit at staff frequently. LPA reviewed facility documentation in which it documents R1 yelled, insulted, spit or hit at staff 8 different times. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED.

LPA investigated allegation, "Staff not seeking medical attention". R1 reported to relevant party that facility refused to send resident out to seek medical attention for 5 days before calling emergency services. LPA interviewed administrator, in which they stated on 9/18/20 R1's appetite decreased and they had a cough. Administrator stated resident did not want to be sent out at that time. Later that evening on 9/18/20, Administrator called emergency services for R1. LPA interviewed 3 residents at the facility, in which they stated the staff would call emergency services if they requested. One resident stated in January 2021 they had pressure in their chest and the staff immediately called 911 for them. Due to the conflicting information LPA finds allegation to be UNSUBSTANTIATED.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20200921134841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MINNESOTA HOME CARE
FACILITY NUMBER: 342700284
VISIT DATE: 07/07/2021
NARRATIVE
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LPA reviewed 4 residents medications comparing with physician orders. LPA found facility had missing medications for 4 of 4 residents when compared to physician orders. Administrator stated they do not have discontinue orders or documentation from the doctor to reflect current medications available to residents. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met: Refer to the 9099-D.

Exit interview conducted and appeal rights given.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20200921134841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MINNESOTA HOME CARE
FACILITY NUMBER: 342700284
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.
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Administrator agrees to obtain current physician orders and medications prescribed. Administrator to send into CCL a plan of how staff will manage residents medications and
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This requirement is not met as evidenced by: Based on observation and record review the licensee did not assist residents with medications as prescribed which poses an immediate health and safety risk to residents in care.
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 obtain physician documentation. POC due by 7/8/21.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7